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Hon. Jeff Miller, Chairman, Full Committee on Veterans' Affairs

Good morning.  This hearing will come to order.

Before we proceed, I would like to take care of an item of Committee business by welcoming our two newest members, Representatives Turner and Amodei, and adopting a resolution filling our Subcommittee rosters for the remainder of the 112th Congress. 

Representative Mark Amodei represents the second district of Nevada, which covers most of the state.  Representative Amodei is also a veteran, having served as a J.A.G. officer in the United States Army.  Before joining us here, he also served as a state senator in Nevada. 

I’d also like to welcome another Army veteran to the Committee. Congressman Bob Turner represents New York’s ninth district, in New York City, where he has been a lifelong resident.  He has also worked 40 years in the television industry as a leader of both small and large companies. 

Should either of you like to say a few words, you are now recognized. 

For the purpose of creating subcommittee vacancies for our new members, I first would like to ask unanimous consent of the Full Committee to accept the removal of Representative Flores of Texas from the Disability Assistance and Memorial Affairs Subcommittee and Representative Denham from the Economic Opportunity Subcommittee.

Hearing no objection, so ordered. 

I thank Representatives Flores and Denham for their working with the Committee to accommodate our new members.    

The list is before the members and I ask Mr. Bilirakis for a motion on this resolution.   

[Adoption of resolution]

Again, welcome to you both.

That concludes our business meeting and I would now turn the Committee’s attention to today’s scheduled hearing titled “Failures at Miami VAMC: Window to a National Problem”.

Welcome to our witnesses.  Because of some of the detail we will cover today I have thought long and hard about deviating from standard Committee practice by requiring each of you to be sworn in before giving your testimony.  At this time, I do not think that is necessary.  I trust that each of you would, and will, provide nothing but truthful answers to us.   That said, we will be listening carefully to what you say and I reserve the right, at any moment, to put you under oath.  Is everyone clear on that?  Good, then let’s proceed.

Some of the issues plaguing the VA Medical Center in Miami are not new to this Committee. 

The facility came into the spotlight in 2009 when it was discovered and reported that endoscopes were not reprocessed correctly, placing over two thousand veterans at risk of exposure to disease. 

Nearly two years later, after the initial round of notifications, 12 additional veterans were identified as being at risk of exposure. 

Putting veterans at risk is inexcusable. 

But failure to identify and notify everyone at risk because patient logbooks were locked away in a safe is nearly impossible to believe. 

I only say “nearly impossible” because that is what, in fact, happened. 

However, the issues we are discussing today extend well beyond sterilizing reusable medical equipment. 

At the heart of this issue is leadership at VA- at all levels and in all parts of the country. 

It is my belief that the failures in leadership and patient safety that were brought to light in 2009 are still occurring to this day. 

Multiple investigations have taken place, disciplinary recommendations put forth, new processes and procedures developed, new policies established- yet the problems are not fixed. 

Earlier this year, VA told this committee in a briefing that things were running smoothly in Miami. 

However, the VA Inspector General released a report in August detailing how, in one case, 50% of the facility employees still failed to properly sterilize reusable equipment. 

Recent news reports are also troubling.

For example, This summer we read about,  an Air Force veteran was brought to the Miami VAMC from neighboring Jackson Memorial Hospital. 

The veteran had been admitted to the hospital earlier by a friend after threatening suicide. 

Once it was realized she was a veteran, she was transferred to the Miami VAMC. 

The veteran then escaped and committed “suicide by cop,”, just one day after she had been admitted to a system that should have protected her in her clearly fragile state of mind. 

In another troubling story released last month, the Miami Herald reported on its findings contained within one of several administrative investigation boards, or “AIBs”, conducted at the Miami VAMC in the wake of the colonoscopy equipment cleaning problems and subsequent notifications to veterans. 

As the Herald noted, disciplinary action was recommended for a “lack of oversight” by hospital leadership. 

The article also noted that the hospital’s director was reinstated less than two months after the report’s recommendations were completed, and that VA declined to comment on what actions were taken based on the recommendations. 

It is the Committee’s desire that today’s witnesses outline a clear process for VA’s leaders in preventing and fixing failures that compromise the safety of our veterans. 

The Committee also needs to hear about how a stricter and comprehensive process can be put into place so that necessary information flows to all levels at VA, from the local level to the network level to Central Office. 

We know that currently there is much that goes unreported, and given the public, repeat offenses, a solution from VA is overdue.

VA must also outline how compliance with department policies is enforced. 

If employees are circumventing patient safety policies, they must be held accountable. 

If policies made by Central Office can easily be circumvented, then policy makers at VA must be held accountable, and meaningful, enforceable policies put forth. 

A related expectation by the Committee is that existing VA policies in place can, and will, be followed by all employees. 

If policies are disregarded or willfully ignored, there should be enforcement mechanisms in place and the right people held accountable. 

Otherwise, policies become words on paper and little more. 

An important point to keep in mind throughout today’s hearing, and moving forward, is that the problems we are discussing are not limited to Miami, or even VISN 8. 

The Committee is well aware of similar problems at VAMCs all across the country. 

More than once, VA has come before us and said problems at its facilities are fixed and “all is well.” 

More than once, that has been shown not to be the case. 

The Miami facility is one glaring example of this national occurrence.    

Just as it should be unacceptable to Secretary Shinseki to be told one thing about how VA facilities are faring, only to subsequently be told otherwise, it is beyond unacceptable for that to occur before this Congressional oversight Committee. 

All of us must be vigilant in rooting out misleading or incomplete information that only serves to keep the truth from full view, and ultimately harms those we all serve in our common mission...the veterans of this country. 

Thank you.  I appreciate everyone’s attendance at this hearing and I now yield to the ranking member for an opening statement.